5 ways states can pave path to medical homes, ACOs

By Mary Mosquera
02:23 PM
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States can start laying the foundation for putting in place delivery system and payment reforms, such as patient-centered medical homes and accountable care organizations (ACOs), with the resources that they have now.

Virtually every state is considering or developing new policy approaches that address coverage, access, quality and delivery system reform and cost control, according to John Colmers, vice president for healthcare transformation and strategic planning for Johns Hopkins Medicine.

“Whether that’s being driven by the payer or provider community or the interests of the state, those are going to be major topics at the state level,” he said Jan. 3, speaking on his own behalf, in an online presentation sponsored by the National Academy for State Health Policy (NASHP).

Even with budget limitations, states have existing policy levers that they can activate to help them build the foundation to establish delivery system and payment reforms, Colmers said, including:

1. States as purchasers: Medicaid is under a lot of change and innovation in states, whether based on state budgets or ACA implementation. State Medicaid programs are trying out managed care activities or pay for performance and encouraging patient-centered medical homes to deliver care. The same applies to states purchasing care for their employees and retirees. Other large purchasers, payers and provider systems are also affecting how the delivery systems in states are organized, for example through grants funded by the Center for Medicare and Medicaid Innovation.

2. States as regulators: States will describe essential health benefits and accompanying care delivery components as they develop their health insurance exchanges. Over the long term, states will have more opportunity to operate the market and the degree to which the exchange operates in collaboration and coordination with commercial payers and Medicaid. “States can become much more of an active purchaser, and it might be an important role for states to play to help move along the continuum,” Colmers said. States can also require reporting public information on price, quality, outcome and other measures. Insurance commissioners, by virtue of their rate authority, can take actions that encourage and compel carriers and providers to act to drive the market through different rate condition approvals, affordability standards and provider contracting standards.

“There’s nothing like an insurance commissioner saying no to a carrier’s rate increase and telling them to come in with something more reasonable or that would compel them to act differently in the manner in which they contract with private providers in their community,” he said. 

3. States as conveners: Senior state officials or legislative committee leadership can bring together individuals or create a healthcare reform task force to bring providers and payers together to develop a planning process or to get consensus around the manner in which they want to have their healthcare systems designed.

4. States as market enablers. States can encourage or move along market changes in health IT and health information exchange or conditions for multiple payers in a state for such development, such as multi-payer patient center medical home activities and ACO development with multiple payers.

Even in states where legislators and policymakers have balked at payment and delivery reform, states can act as a convener, Colmers said.

“While people may not want to admit that there are problems, payment levels around Medicaid and Medicare are going to compel providers to act very differently and create an environment where you can have a dialogue around that and invite executive and legislative branch leaders to move forward,” he said.

5. States as data holders: States have to respond within the environment that exists, according to Chris Koller, Rhode Island Health Insurance Commissioner. A good place to start is with established data and evidence databases.

“Whenever you can take on issues where you have a particularly local fact base to support it, it allows you to be more of an observer and start to educate people about what is going on,” he said. 

The role of primary care is a topic with a significant evidence base and not a lot of political resistance. “It’s pretty hard to argue the centrality of primary care for the healthcare system and the way it has been fundamentally marginalized. That’s a pretty good political base from which to start these conversations,” Koller said.

Related Q&A: MedAllies' Holly Miller and John Blair on moving from PCMH to a 'medical neighborhood' via Direct